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Course: Pediatric Nursing

Topic: Nursing care of Child with Gastrointestinal Disorder Part II

The Nurses International Community

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Module Goals

Learners will be able to:

Identify common gastrointestinal illnesses of childhood including signs and symptoms (oral thrush, appendicitis, GERD, PUD, constipation).
Identify risk factors associated with the above gastrointestinal disorders.
Describe common diagnostic procedures for the above gastrointestinal disorders and nursing implications.
Explain common medical treatments for children with the above gastrointestinal disorders and nursing implications.
Discuss the nursing management of a child with the above gastrointestinal disorders.

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Oral Thrush or Candidiasis, Cause, Diagnosis

Oral candidiasis or thrush is an infection of the oral cavity

Vaginal Candida infections can colonize neonates as they pass through the birth canal
Neonates and infants may contract the disease through colonized breasts when breastfeeding

Cause: Candida albicans

Diagnosis:

Inspection of the inside of the mouth and throat
throat or mouth swab

CDC, 2021

NHS, 2020

Taylor & Raja, 2021

Contact info: info@nursesinternational.org

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Candidiasis: Risk Factors

Infants, especially younger than 1 month of age, and with at least one of these factors

Very low birth weight
Passed through the birth canal of a mother with a yeast infection
Has taken antibiotics
Uses inhaled corticosteroids, such as for asthma
Uses a pacifier frequently
Has a weak immune system

University of Rochester Medical Center, n.d.a

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Candidiasis: Signs and Symptoms

White patches on the inner cheeks, tongue, roof of the mouth, and throat
Redness or soreness in the mouth
Cotton-like feeling in the mouth
Loss of taste
Pain while eating or swallowing
Cracking and redness at the corners of the mouth

CDC, 2021

NHS, 2020

Taylor & Raja, 2021

Contact info: info@nursesinternational.org

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Candidiasis: Treatment

Depends on child’s age, severity, symptoms and general health.
Healthy infants with mild thrust may not need treatment.
Severe cases are treated with antifungals (clotrimazole, miconazole, or nystatin).
If breastfeeding, both mother and baby are treated with antifungals.
Good oral hygiene.
Sterilization of toys, pacifiers, and teethers.

CDC, 2021

NHS, 2020

Taylor & Raja, 2021

Contact info: info@nursesinternational.org

Treatment will depend on the child’s symptoms, age, and general health. It will also depend on how severe the condition is.

A healthy baby with mild thrush may not need any treatment. More severe cases are likely to be treated with a liquid antifungal medicine. This is given through a dropper into the child’s mouth. Or the medicine may be given as pills in an older child.

Breastfeeding mothers may develop thrush on their nipples. If breastfeeding, both mother and the child will be treated. This is to prevent passing the infection back and forth. Mother may be given an ointment to apply to the skin or an oral antifungal medicine.

Talk with the child’s healthcare providers about the risks, benefits, and possible side effects of all medicines.

It is important to boil (sterilize) and disinfect any pacifiers, bottle nipples, or toys that the child may put in their mouth after each use. This will prevent the child from being infected again.

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Candidiasis: Nurses’ Role

Ensure good oral hygiene; demonstrate practice with return demonstration by client or caregivers.
Administer medications for inpatients: Teach how to swill and swallow.
Provide counseling and support.
Assess oral cavity frequently and note any changes: color, bleeding, ulceration, exudate.
Monitor nutritional and hydrational status.
Provide soft diet with severe dysphagia.
Relieve pain (medication)/discomfort at least an hour before meal.

Nurses Lab, 2022

Contact info: info@nursesinternational.org

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Client Education

Education for client or caregivers about importance of:

Good oral health
Rinse or brushing teeth after using using inhaled corticosteroids
Wash hands before and after caring for the child
Hand washing in older children
Sterilize bottle or pacifier after each use
Do not wipe off the white patches as they may bleed
Brush gums and tongue of babies with a soft toothbrush

CDC, 2021

NHS, 2020

Taylor & Raja, 2021

Contact info: info@nursesinternational.org

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Critical Thinking Question

A nurse is explaining to parents how the antifungal drug i.e Nystatin should be taken. The mother of of the child asks the nurse what “Swish and Swallow” means?

How would the nurse respond “Swill and Swallow”?

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Appendicitis

Inflammation of appendix
Rare in children < 3 years of age
Very difficult to diagnose, especially in younger children therefore, the index of suspicion should be high

Causes:

Obstruction of the opening of the appendix
The blockage may be caused by mucus, stool, or parasites

Or by a bend or twist in the appendix itself

Government of Canada, 2013; University of Rochester Medical Center, n.d.b

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Appendicitis: Risk and Diagnostic Tests

Risk:

Children between the ages of 10 and 30 years
Children with cystic fibrosis
Family history of appendicitis

Diagnostic Tests:

Blood test: WBC count
Urinalysis to rule out urinary tract infection
Blood cultures if fever is present and diagnosis uncertain
Ultrasound and CT scan (if available)

Government of Canada, 2013

University of Rochester Medical Center, n.d.b

Contact info: info@nursesinternational.org

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Appendicitis: Signs and Symptoms

Physical Findings:

Presentation depends on child’s age, evolution of disease process

Temperature mildly elevated
Tachycardia (although heart rate may be normal in early stages)
Variable level of distress
Change in behavior
Loss of appetite
Swollen abdomen in younger children

Government of Canada, 2013; University of Rochester Medical Center, n.d.b

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Appendicitis: Signs and Symptoms

Abdominal Examination

Bowel sounds variable: hyperactive to normal in early stages, absent in later stages
Localized tenderness in right lower abdominal quadrant
Muscle guarding in right lower quadrant
Rebound tenderness may be present
Obturator sign
Psoas sign

Government of Canada, 2013; University of Rochester Medical Center, n.d.b

Contact info: info@nursesinternational.org

Abdominal Examination

Bowel sounds variable: hyperactive to normal in early stages, reduced to absent in later stages
Localized tenderness in right lower quadrant
Muscle guarding in right lower quadrant
Rebound tenderness may be present
Obturator sign (pain on internal rotation of flexed right knee and hip). If there is pain in right abdomen it may indicate irritation of the obturator muscle or peritoneum due to an inflamed appendix
Psoas sign (pain on raising straight right leg against resistance just above knee while supine) may indicate abscess or irritation of the psoas muscle or peritoneum by an inflamed appendix

Another test for peritoneal irritation is to have the child jump off the examining table. If the child can do this without pain, he or she probably does not have appendicitis.

Rectal Examination

Tenderness may be present in right lower quadrant if appendix is near the rectum

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Appendicitis: Treatment and Management

Appendicitis is an medical emergency
Prompt surgery prevents rupture of the appendix
Treated with antibiotics and surgery
Surgery (appendectomy) to remove appendix
Mild cases of appendicitis may be treated with antibiotics alone
Goals of treatment is to maintain hydration and prevent complications

Government of Canada, 2013; University of Rochester Medical Center, n.d.b

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Appendicitis: Treatment and Management

Adjuvant Therapy

Initiate intravenous therapy with normal saline

Nonpharmacologic Interventions

Bed rest
Nothing by mouth
Possible nasogastric tube upon consultation

Pharmacological Interventions:

Broad spectrum antibiotics

Government of Canada, 2013

University of Rochester Medical Center, n.d.b

Contact info: info@nursesinternational.org

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Appendicitis: Nurses’ Role

Assess and relieve pain (pharmacological/ non-pharmacological)
*Do not apply heat to the site as it could lead to rupture
Prevent fluid volume deficit
Maintain clean environment to prevent infections
Reduce clients and caregivers anxiety by explaining treatment plan
Encourage the child to walk if able, if not provide SCD pumps, TED hose to prevent DVTs
Encourage fluid intake, monitor intake and output and bowel movements

Jones et al., 2021

Contact info: info@nursesinternational.org

Nursing interventions related to the appendicitis patient include:

Assessing and relieving pain through medication administration as well as nonpharmacologic interventions.
*IMPORTANT: DO NOT APPLY HEAT TO THE APPENDICITIS PATIENT'S ABDOMEN AS THIS COULD LEAD TO RUPTURE.
Prevent fluid volume deficit. If tolerated and the patient is not NPO, oral fluid intake should be encouraged, and intake and output recorded.
Prevent infection. Maintain a clean environment, provide wound care to the postoperative patient, and assess incision frequently for signs of infection. Monitor patient temperature and heart rate for signs of potential infection. Administer antibiotics as prescribed by the provider.
Reduce patient anxiety by keeping the patient informed of the plan of care and ensure the patient is aware of diagnosis and treatment options.
Encourage patients to walk as able/ permitted to maintain circulation. If the patient is immobile, the use of serial compression devices (SCD) and TED hose should be implemented to avoid DVT/clots.
Monitor for adequate bowel movements. Opioids can be necessary for pain control, but they often lead to constipation. Encourage adequate water intake and use of a stool softener.

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Critical Thinking Question

An 14 year old is admitted to the ward with appendicitis. Which statement by the patient requires immediate nursing intervention?

“The pain is becoming worse and it is making me nauseous."
"The pain sits on the right lower quadrant and it hurts when pressed and released"
"The pain has reduced after I applied a heating pad on the abdomen."
The pain is worse when I lie supine position and raise my right leg up."

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Gastroesophageal Reflux Disease (GERD)

Physiologic conditions or pathologic disease causes retrograde movement of gastric contents into the esophagus, which results in injury to the esophagus and extra-intestinal disease.
This causes GI, respiratory and/or neurobehavioral manifestations.
In children, the peak age at onset is 1-4 months of age.

Risk: Children with neurologic injury are more likely to have GERD

Government of Canada, 2013

Rybak et al., 2017

Contact info: info@nursesinternational.org

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GERD: Cause

Causes: Disturbance of the normal functioning of the esophagus & related structures .

Gastric Dysfunction: Delay in gastric emptying, fundus does not relax.
Increased Relaxation of Lower Esophageal Sphincter: Transient relaxation of lower esophageal sphincter.
Esophageal Dysfunction: Impairment of esophageal clearance of refluxate.
Aggravating Factors: Supine position & certain foods and medications.

Government of Canada, 2013

Rybak et al., 2017

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GERD: Diagnostic Tests

Hemoglobin level (if there is a concern about anemia).

Chest x-ray (if available), to rule out aspiration or recurrent pneumonia.

Government of Canada, 2013

Rybak et al., 2017

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GERD: Signs and Symptoms

In infants:

Gastrointestinal

Failure to thrive
Malnutrition
Esophagitis
Feeding problems
Irritability
Hematemesis
Anemia

Government of Canada, 2013

Rybak et al., 2017

Respiratory

Apnea (obstructive)
Chronic cough
Wheeze
Pneumonia (chronic or recurrent)
Cyanotic spells
Others (for example, stridor, hiccups, hoarseness)

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GERD: Signs and Symptoms

Children and Adolescents

Gastrointestinal

Chest pain (heartburn)
Dysphagia (difficulty swallowing)
Halitosis
Odynophagia
Water brash
Hematemesis
Iron deficiency anemia

Government of Canada, 2013

Rybak et al., 2017

Respiratory

Recurrent or chronic pneumonia
Recurrent wheeze (GERD is a trigger for reactive airways disease or asthma)
Chronic cough
Others (for example, stridor, hoarseness)

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GERD: Treatment & Management

Pharmacological:

Acid reducing agents: Aluminium-magnesium hydroxides, proton-pump inhibitors
Prokinetic agents: Domperidone

Non-pharmacological interventions:

Client education
Positioning
Feeding

Note: Surgery may be necessary in severe cases

Government of Canada, 2013

Rybak et al., 2017

Contact info: info@nursesinternational.org

Management

Goals of Treatment

Eliminate detrimental effects of reflux (GI, respiratory and neurobehavioral manifestations)

Nonpharmacologic Interventions

Client Education: to explain difference between physiologic conditions and pathologic disease that cause reflux.
Positioning: Upright position after eating
Feeding: Encourage fasting for a few hours before child goes to sleep, avoid large meals (that is, promote smaller, but more frequent feedings)

Pharmacologic Interventions (for Older Children and Adolescents)

Medications for an infant or young child must be ordered by a physician. The medications presented here are for older children and adolescents (≥12 years).

Acid-Reducing Agents: Used more often in older children who have pain associated with esophagitis:

Aluminum-magnesium hydroxides suspension (for example, Alumag), 0.5-1 mL/kg PO 3-6 times per day. This should only be given for short-term use. Proton pump inhibitors (for example, omeprazole [Losec]) are frequently used as well and must be ordered by a physician.

Prokinetic Agents: Prokinetic agents (for example, domperidone [Motilium]) may be used in severe cases where complications arise or are expected. It must be ordered by a physician.

Surgery may be necessary in severe cases.

Indications for surgery:

Failure of medical management
Severe or intractable detrimental effects (for example, failure to thrive, recurrent pneumonia, peptic stricture)
Neurologically impaired children with or without gastrostomy tube

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GERD: Nurses’ Role

Raise the head of the child's bed 15 to 20 degrees
Have the child eat smaller but frequent meals
Avoid foods that trigger GERD ( chocolate, spicy food, oranges, tomatoes)
Abstain from food 2 to 3 hours before bedtime
Administer medicines as prescribed
Proper client education on feeding, positioning
Proper monitor and follow ups

Government of Canada, 2013

Rybak et al., 2017

Contact info: info@nursesinternational.org

Client Education

Discuss diagnosis with parents or caregiver and explain difference between physiologic conditions and pathologic disease that cause reflux.

Positioning

Place child in upright or prone (if supervised) positions
Do not prop bottle when feeding child
Avoid supine or semi-seated position
Elevation of head of bed onto 6 inch (15 cm) blocks may be useful

Feeding

Thicken infant foods (add 1 tbsp [15 mL] dry rice cereal for each ounce of formula)
Encourage fasting for a few hours before child goes to sleep
Avoid large meals (that is, promote smaller, but more frequent feedings)
Diet for weight loss may be considered in an older child, if he or she is overweight or obese
Avoid foods that decrease LES pressure or increase gastric acidity (for example, carbonated drinks, fatty foods, citrus fruits, tomatoes)
Avoid tight-fitting clothes
Avoid exposure to tobacco smoke

Monitoring and Follow-Up

Reassess monthly while the child is symptomatic. Watch carefully for signs of complications (for example, failure to thrive, recurrent pneumonia, asthma, erosive esophagitis or anemia). Monitor growth and development, hemoglobin level and lung sounds.

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Case Study

During a home health visit, a nurse is helping a mother of 13 years old develop a list of foods to avoid GERD in her child.

Which food items should be avoided?

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Peptic Ulcer Disease (PUD) in Children

A peptic ulcer is erosion of the lining of the stomach or duodenum by the stomach acid or digestive enzymes.

Causes:

*Helicobacter pylori (H. pylori)
*NSAIDS medications
Bacteria infection, exposure to smoking, caffeine, stress, acid and pepsin, chemotherapy

Risk Factors:

Factors that make H.Pylori infection more likely (sharing bed, living in crowded environment, genetics)

Stanford Children's Health, n.d.

Ocasio Quinones et al., 2021

Contact info: info@nursesinternational.org

The two primary causes for duodenal ulcers are a history of recurrent or heavy NSAID use and a diagnosis of H. pylori. The majority of patients carry a secondary diagnosis of H. pylori; however, as infection rates have declined, other previously uncommon etiologies are becoming more prevalent. Other causes of duodenal ulcers include etiologies that, in similar ways to NSAIDs and H. pylori, disrupt the lining of the duodenum. Some of these include Zollinger-Ellison syndrome, malignancy, vascular insufficiency, and history of chemotherapy.

H. pylori infection occurs when H. pylori bacteria infect the stomach. H. pylori bacteria are usually passed from individual to individual through direct contact with saliva, vomit or stool. H. pylori may also be spread through contaminated food or water. The exact way H. pylori bacteria causes gastritis or a peptic ulcer in some people is still unknown.

Risk factors

People often get H. pylori infection during childhood. Risk factors for H. pylori infection are related to living conditions in childhood, such as:

Living in crowded conditions. Living in a home with many other people can increase the risk of H. pylori infection.
Living without a reliable supply of clean water. Having a reliable supply of clean, running water helps reduce the risk of H. pylori.
Living in a developing country. People living in developing countries have a higher risk of H. pylori infection. This may be because crowded and unsanitary living conditions may be more common in developing countries.
Living with someone who has an H. pylori infection. A child is more likely to have H. pylori infection if living with someone who has H. pylori infection.

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PUD: Diagnosis

Upper gastrointestinal series: X-ray -swallow metallic liquid (barium).

Endoscopy: To visualize the lining of upper GI tract and take biopsies for test.

Blood, breath, stomach tissue and stool: Lab test for the presence of H. Pylori

Stanford Children's Health, n.d.

Ocasio Quinones et al., 2021

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PUD: Signs and Symptoms

Gnawing pain
Burning pain
Aching
Soreness
Feeling of hunger
Infants, fussy and irritable during or after feedings
Young children many not have typical symptoms. May have abdominal pain and vomiting

Stanford Children's Health, n.d.

Ocasio Quinones et al., 2021

Contact info: info@nursesinternational.org

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PUD: Treatment and Management

Treatment depends on the child’s age, severity of the condition, and general health condition

The basic treatment includes:

Lifestyle change: No smoking
Medicine: Antibiotics, H2 -blockers, PPIs
Surgery: If child does not respond to the medication

Stanford Children's Health, n.d.

Ocasio Quinones et al., 2021

Contact info: info@nursesinternational.org

Treatment will depend on the child’s symptoms, age, and general health. It will also depend on how severe the condition is.

Lifestyle changes: Before it was believe that spicy or fatty foods caused PUD but now it has been known that no such foods contribute PUD. However there are certain foods that may make the ulcer worse. Some children and Teenagers may smoke contributing to ulceration. Therefore, changing such habits help treating PUD.
Medicines: If H. pylori is found in test, then the child will be treated with antibiotics, H2-blockers like Cimetidine , Proton pump inhibitors like pantoprazole, mucosal protective agents.
Surgery: Surgery is ultimate solution if medicine and lifestyle change don't work. However, it is very uncommon. In most cases medicine works.
PPIs, H2-receptor antagonists work by reducing the amount of acid the stomach produces. Ranitidine is the most widely used H2-receptor antagonist for treating stomach ulcers.

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PUD: Nurses’ Role

Take appropriate history related to chest and abdominal pain
Detailed assessment of child's eating habits
Encourage the use of nonpharmacological methods, including change in diet, biofeedback, walk after the meals, and elevation of the head end of the bed
Avoid non-steroidal anti-inflammatory drugs (NSAIDs) such as piroxicam, ibuprofen, aspirin
Encourage smoking cessation
Administer therapy as prescribed

Ocasio Quinones et al., 2021

Contact info: info@nursesinternational.org

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PUD: Nurses’ Role

Manage pain, anxiety
Maintain adequate nutrition
Monitor intake and output
Regularly monitor hemoglobin and hematocrit levels
Assess the characteristic of vomitus
Educate child and care providers about the management and prevention of PUD

Ocasio Quinones et al., 2021

Contact info: info@nursesinternational.org

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Constipation

Infrequent passage of hard and dry stool
Common in children in the first year of life
Constipation is a symptom not a diagnosis
It has an underlying cause

Causes:

Dietary: cow’s milk, low fiber diet, inadequate fluid intake
Organic: Diabetes mellitus
Gastrointestinal anomalies: masses, Hirschsprung’s diseases

Government of Canada, 2013

Contact info: info@nursesinternational.org

Constipation

Infrequent passage of hard, often dry stool. In 99% of cases, the cause of the constipation is never proven definitively. The condition is common in children, and often (in 60% of cases) occurs during the first year of life.

Constipation is a symptom, not a diagnosis. In all cases, the underlying cause must be sought, as many of the causes are correctable.

Causes

Dietary

Introduction of cow's milk
Inadequate fluid intake
Undernutrition
Diet high in carbohydrates or protein (or both)
Low-fibre diet

Organic

Diseases causing abnormally dry stool
Diabetes insipidus or diabetes mellitus
Fanconi's syndrome
Idiopathic hypercalcemia

Gastrointestinal Anomalies

Hirschsprung's disease (congenital megacolon)
Anorectal stenotic lesion, stricture or fissure
Masses (intrinsic or extrinsic)
Anterior anal displacement

Central Nervous System Lesions

Hypotonia (benign congenital hypotonia)
Hypertonia (cerebral palsy)

Other Causes

Hypothyroidism
Prune-belly syndrome
Coercive toilet training
Medications (for example, narcotic analgesics, iron)
Lack of exercise
Stress

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Constipation: Diagnosis and Assessment

Diagnostic Tests

Stool for blood
Check urine (culture and sensitivity) to exclude UTI

Assessment

Assess height, weight
Assess abdomen for tenderness, mass and fecal masses
Examine rectum for size, presence of stool, reflex, tone, anal fissure, anal placement

Government of Canada, 2013

Contact info: info@nursesinternational.org

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Constipation: Management

Nonpharmacologic Interventions

Interventions depend on age and severity of constipation.

Extra daily feeding of 2-4 oz. of water in addition to usual formula or breast milk
Infants (> 6 months), toddlers and older children: prune juice, apple juice or pear juice;increase fruits and vegetables in diet
Increase dietary fiber
Increase fluid intake, particularly water

Government of Canada, 2013

Contact info: info@nursesinternational.org

Management

Goals of Treatment

Rule out gastrointestinal emergency
Relieve symptoms
Establish regular bowel function
Determine if there is any underlying cause
Prevent or treat complications
Encourage wise use of laxatives, to prevent dependence on these drugs

Consultation

Consult a physician if constipation is not resolving despite interventions.

Nonpharmacologic Interventions

Interventions depend on age and severity of constipation.

Give extra daily feeding of 2-4 oz. (60-125 mL) of water in addition to usual formula or breast milk
Infants (> 6 months), toddlers and older children: prune juice, apple juice or pear juice may be effective; as solid foods are introduced, gradually increase fruits and vegetables as proportion of the diet. Prunes may also be effective
Increase dietary fibre, if low
Increase fluid intake, particularly water

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Constipation: Pharmacological Interventions

Medications used only if:

Organic pathology has been ruled out
An infant or child is in distress
For infants and small children use Glycerin suppository

In older children:

Oral suspension of magnesium hydroxide
Lactulose
Physician should be consulted before use

Government of Canada, 2013

Contact info: info@nursesinternational.org

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Critical Thinking Question

Which of the following statement made the mother indicates her child might be at the risk of having constipation?

“I have switched to cow’s milk and my 11 months baby loves to drink a whole bottle of milk.”
“I have started introducing green leafy vegetables to my 9 months old child.”
“My baby is 8 months and still breastfeeding and gets home cooked chicken soup as supplement.”
“I have 13 months old baby who loves apple and prunes along with the formula.”

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Red Flags

All of the signs and symptoms of gastrointestinal disorders are considered as red flag in child and it needs immediate medical help.

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Health beliefs: In some cultures talking about a possible poor health outcome will cause that outcome to occur.
Health customs: In some cultures family members play a large role in health care decision-making.
Ethnic customs: Differing gender roles may determine who makes decisions about accepting & following treatment recommendations.

AHRQ, 2020

Contact info: info@nursesinternational.org

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Cultural Considerations (Continued)

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may effect health seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family.
Interpersonal customs: Eye contact or physical touch may be ok in some cultures but inappropriate or offensive in others.

AHRQ, 2020

Contact info: info@nursesinternational.org

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Cultural Considerations: Examples

Children with Hispanic and African-American backgrounds have a higher risk of developing Peptic Ulcer Disease.

IBS, bloating, constipation, chronic functional abdominal pain, and pelvic floor dysfunction, are more prevalent in women than men.

Chuah & Mahadeva, 2018

Contact info: info@nursesinternational.org

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References:

CDC- Centers for Disease Control and Prevention. (2021, Feb 25). Candida infections of the mouth, throat, and esophagus. https://www.cdc.gov/fungal/diseases/candidiasis/thrush/index.html

Chuah, K. H., & Mahadeva, S. (2018). Cultural Factors Influencing Functional Gastrointestinal Disorders in the East. Journal of neurogastroenterology and motility, 24(4), 536–543. https://doi.org/10.5056/jnm18064

Government of Canada. (2013). Clinical Practice Guidelines for Nurses in Primary Care:Pediatric and Adolescent Care - Chapter 12 - Gastrointestinal System. https://www.canada.ca/en/indigenous-services-canada/services/first-nations-inuit-health/health-care-services/nursing/clinical-practice-guidelines-nurses-primary-care/pediatric-adolescent-care/chapter-12-gastrointestinal-system.html#a18

Contact info: info@nursesinternational.org

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References:

Jones MW, Lopez RA, Deppen JG, et al. (Updated 2021 Sep 9). Appendicitis (Nursing). StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK568712/

NHS. (2020, July 8). Oral thrush (mouth thrush). https://www.nhs.uk/conditions/oral-thrush-mouth-thrush/

Nurses Lab. (2022). Impaired Oral Mucous Membrane Nursing Care Plan. https://nurseslabs.com/impaired-oral-mucous-membrane/

Ocasio Quinones GA, Woolf A, Haddad LM. (Updated 2021 Apr 26). Duodenal Ulcer (Nursing) StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK568678/

Contact info: info@nursesinternational.org

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References:

Rybak, A., Pesce, M., Thapar, N., & Borrelli, O. (2017). Gastro-Esophageal Reflux in Children. International journal of molecular sciences, 18(8), 1671. https://doi.org/10.3390/ijms18081671

Stanford Children's Health. (n.d.). Stomach and Duodenal Ulcers in Children. https://www.stanfordchildrens.org/en/topic/default?id=stomach-and-duodenal-ulcers-peptic-ulcers-in-children-90-P02021

Taylor, M., Raja, A. (2021 Jul 25). Oral Candidiasis. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK545282/

Contact info: info@nursesinternational.org

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References:

University of Rochester Medical Center. (n.d.a). Encyclopedia: Thrush (Oral Candida Infection) in Children. https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=90&contentid=P02690

University of Rochester Medical Center. (n.d.b). Encyclopedia: Appendicitis in Children. https://www.urmc.rochester.edu/encyclopedia/content.aspx?ContentTypeID=90&ContentID=P01981

Contact info: info@nursesinternational.org

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